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Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Alert

Prevent Denials

Before a PA request is submitted, ensure your facility understands the difference between cosmetic vs. reconstructive procedures. The medical record must also support that the services are medically reasonable and necessary. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). Items and services which are not reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member are not covered services.

Background

Title XVIII of the Social Security Act section 1862 (a)(1)(A) allows coverage and payment of those services that are medically reasonable and necessary. In the absence of a local coverage determination (LCD), CGS utilizes the Centers for Medicare & Medicaid Services (CMS) based regulatory guidance, national coverage determinations (NCDs), evidence-based specialty guidelines, and high quality published literature to establish medical necessity. See CMS Regulation Reference: Publication 100-08, Chapter 3, Section 3.6.2.2 for Reasonable and Necessary CriteriaExternal PDF.

Coverage and Documentation Requirements

Meeting medical necessity requirements remain unchanged for certain hospital OPD services for dates of services (DOS) on or after July 1, 2020 in order to protect the Medicare Trust Fund from improper payments. The patient s medical record must contain documentation to fully support that services are medically reasonable and necessary. Reimbursement for a non-covered procedure performed during the same operative session as a covered surgical procedure will not be covered.

The patient s medical record should include but is not limited to:

  • Assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed)

Is the Service Being Performed Cosmetic or Reconstructive?

Reconstructive items and services are reasonable and necessary for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member are covered. Cosmetic procedures or expenses incurred in connection with such procedures (addressing aesthetic appearance alone) will not be covered.

Cosmetic Procedures

Cosmetic procedures include surgical procedures directed at improving appearance, except when required for the prompt repair of accidental injury or for the improvement of the functioning of a malformed body part. For example, procedures solely to improve or enhance the aesthetic appearance is not considered reasonable and necessary.

Indications for Cosmetic Procedures

  • Services performed to improve a patient's appearance in the absence of any signs or symptoms of functional impairment such as:
    • Treatment of wrinkles using Botulinum toxins
    • Corrective facial surgery in the absence of addressing a functional impairment
  • Panniculectomy is performed for the following indications:
    • Removal of unwanted localized collections of fat in order to improve appearance
    • Treatment of neck or back pain
    • Treating psychological symptomatology or psychosocial complaints
    • Hernia repair
    • In conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately
  • Nasal surgery performed solely to improve aesthetic appearance in the absence of any signs and/or symptoms of functional abnormalities
  • Interventional vein ablation treatments for the following indications:
    • Treatment of spider veins (telangiectases)
    • Interventional treatment of asymptomatic varicosities
    • Sclerotherapy for cosmetic purposes

Reconstructive Procedures

Reconstructive procedures include surgical procedures to correct, repair, or restore bodily function of a deformity resulting from trauma/injury, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors (e.g., congenital anomalies, defects). When the service performed is to improve necessary functioning of a malformed body part, the services are considered reasonable and necessary.

Indications for Reconstructive Procedures

  • Blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids
    • Repair defects caused by trauma or tumor-ablative surgery
    • Treat periorbital sequelae of thyroid disease and nerve palsy
    • Relieve painful symptoms of blepharospasm
  • Nasal surgery generally performed to improve:
    • Respiratory function
    • Repair defects caused by trauma
    • Treatment of nasal deformity associated with congenital anomaly such as:
      • cleft lip or cleft palate
      • choanal atresia
      • oronasal or oromaxillary fistula
    • Replace nasal tissue lost after tumor ablation
  • Panniculectomy to correct or relieve:
    • Structural defects of the abdominal wall
    • Improve skin health within the fold beneath the pannus
    • Improve chronic low back pain due to functional incompetence of the anterior abdominal wall
  • Vein ablation treatments will be considered for the following indications:
    • Interventional treatment of varicose veins (e.g., sclerotherapy, ligation with or without stripping)
    • Endovenous radiofrequency or laser ablation
    • Failure of conservative therapy severe enough to require daily pain medications and inability to complete activities of daily living (e.g., pain, swelling, itching, burning, or other symptoms associated with vein reflux)

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